Intensive stuttering modification therapy: a multidimensional assessment of treatment outcomes

Exploring the nature of stuttering through a behavioral-neuro-modulation intervention program in bilinguals with stuttering

PURPOSE

Investigations on identifying the nature of stuttering present varying views. The argument remains whether the stuttering dysfluencies have a motor or a linguistic foundation. Though stuttering is considered a speech-motor disorder, linguistic factors are increasingly reported to play a role in stuttering. Current literature points towards deficits in speech-related motor areas of the brain to abnormalities in linguistic planning and phonological memory playing a role in stuttering. Examining cross-linguistic generalization of treatment gains from treated to untreated language in bilinguals who stutter may provide a unique opportunity to explore the motor and linguistic factors in stuttering.

METHODS

In the current study, we explored this potential by experimentally controlling the language of treatment in bilinguals with stuttering (BWS). We hypothesized that if the dysfluencies in stuttering arise from the underlying motor deficits, then the language of treatment would not play a significant role in cross-linguistic generalization. Sixteen BWS were given transcranial direct current stimulation (tDCS) along with behavioral intervention for three weeks. The language of treatment was randomized, wherein participants in one group received behavioral intervention in their dominant language and the other in their non-dominant language.

RESULTS

Results showed that participants in both groups showed a reduction in their stuttering dysfluencies (% stuttered syllables) regardless of the language of treatment, and the treatment gains were generalized to the non-treated language.

CONCLUSION

Linguistic factors such as language dominance and structure of languages did not surface to play a role in the generalization, signaling the motoric nature of dysfluencies in stuttering.

A Biopsychosocial Overview of Speech Disorders: Neuroanatomical, Genetic, and Environmental Insights

Speech disorders encompass a complex interplay of neuroanatomical, genetic, and environmental factors affecting individuals' communication ability. This review synthesizes current insights into the neuroanatomy, genetic underpinnings, and environmental influences contributing to speech disorders. Neuroanatomical structures, such as Broca's area, Wernicke's area, the arcuate fasciculus, and basal ganglia, along with their connectivity, play critical roles in speech production, comprehension, and motor coordination. Advances in the understanding of intricate brain networks involved in language offer insights into typical speech development and the pathophysiology of speech disorders. Genetic studies have identified key genes involved in neural migration and synaptic connectivity, further elucidating the role of genetic mutations in speech disorders, such as stuttering and speech sound disorders. Beyond the biological mechanisms, this review explores the profound impact of psychological factors, including anxiety, depression, and neurodevelopmental conditions, on individuals with speech disorders. Psychosocial comorbidities often exacerbate speech disorders, complicating diagnosis and treatment and underscoring the need for a holistic approach to managing these conditions. Future directions point toward leveraging genetic testing, digital technologies, and personalized therapies, alongside addressing the psychosocial dimensions, to improve outcomes for individuals with speech disorders. This comprehensive overview aims to inform future research and therapeutic advancements, particularly in treating fluency disorders like stuttering.

CARE Model of Treatment for stuttering: Theory, assumptions, and preliminary findings

The purpose of this article is to present a theory of therapy for stuttering, its related assumptions, and findings from associated empirical studies. Specifically, we propose the Blank Center CARE™ Model of Treatment (CT) for stuttering, which differs from the current, widely employed fluency model of treatment (FT). The CT reflects the authors' belief in the need to move away from fluency-focused or seemingly ableist treatments (i.e., any approach that attempts to correct, cure, or fix a disabling condition) for stuttering. The authors propose a shift toward a theory of treatment that addresses whole-person wellness and considers the treatment of stuttering from outside the framework of fluency shaping and stuttering modification. In support of such considerations, this article provides preliminary findings from both non-clinical and clinical studies of using the CT for children and adults. Although preliminary, these findings appear to lend empirical support to the authors' belief that the treatment of stuttering needs to change. In essence, a change in the zeitgeist regarding the treatment of stuttering may contribute to an associated paradigm shift from FT to CT in the management of stuttering in children and adults.

Self-Perceived Communication Competence of Adults Who Stutter Following Communication-Centered Treatment

PURPOSE

The purpose of this study was to assess self-perceived communication competence of adults who stutter following participation in a non-ableist treatment for which one of the core components focuses on communication - with no direct or indirect goals designed to reduce or modify stuttered speech.

METHOD

Thirty-three adults who stutter completed the Self-Perceived Communication Competence scale (McCroskey & McCroskey, 1988) pre- and posttreatment.

RESULTS

Findings indicate significant gains in self-perceived communication competence posttreatment. Pre- to posttreatment changes in stuttering did not predict posttreatment gains in self-perceived communication competence.

CONCLUSION

The present study demonstrates that improvement in communication can be achieved independent of improvement in fluency, lending further support to the notion that stuttering and communication competence are distinct constructs.

Evaluation of an Integrated Fluency and Acceptance and Commitment Therapy Intervention for Adolescents and Adults Who Stutter

PURPOSE

Developmental stuttering is a complex and multifaceted neurodevelopmental disorder that may cause pervasive negative consequences for adults who stutter (AWS). Historically, intervention for AWS has primarily addressed speech fluency, with less focus on the covert psychosocial aspects of the disorder. The purpose of this article is to report on a feasibility trial evaluating a novel integrated intervention that combines traditional stuttering management techniques with Acceptance and Commitment Therapy (ACT) for AWS.

METHOD

Twenty-nine AWS participated in the feasibility trial. All participants successfully completed a combined fluency and ACT intervention, titled the fluency and Acceptance and Commitment Therapy for Stuttering (fACTS) Program. As this was a feasibility study, no control group was included. Intervention was administered by two certified practicing speech-language pathologists, over eight 60- to 90-min sessions.

RESULTS

Generalized linear mixed modeling was used to determine change from pre- to post-intervention and follow-up. Significant pre- and post-intervention improvements in self-efficacy, psychosocial functioning, and psychological flexibility were observed, along with significant reductions in observable stuttering behaviors (i.e., stuttered speech frequency). Intervention gains for all variables of interest were maintained 3 and 6 months post-intervention.

CONCLUSIONS

The fACTS Program was created to be a holistic and flexible intervention to promote self-efficacy beliefs and address stuttering-related psychosocial impacts and speech fluency goals of AWS. Preliminary results indicated positive improvement in all psychosocial outcomes (i.e., self-efficacy, psychosocial impact, and psychological flexibility) and observable speech fluency following completion of the program. Future clinical trials of the fACTS Program with an included control group will further investigate the mechanisms of change for the positive effects observed.

Self-Stigma of Stuttering: Implications for Communicative Participation and Mental Health

PURPOSE

The purpose of this study was to determine if self-stigma-related variables predicted communicative participation and mental health in adults who stutter. A progressive model of self-stigma was theorized and tested.

METHOD

Adults who stutter (N = 344) completed a survey that included measures of communicative participation, global mental health, and a variety of self-stigma-related variables including perceived enacted stigma, stigma awareness, anticipated stigma, felt stigma, stereotype agreement, and stigma application, in addition to demographic and speech-related variables. Hierarchical regression was performed to test whether self-stigma-related variables progressively explained significant variance in both communicative participation and global mental health.c Results: After controlling for demographic and speech-related variables, stigma-related variables were found to be significant predictors of both communicative participation and global mental health among adults who stutter. Most self-stigma-related variables entered later in the model predicted additional unique variance in the outcome variables than the self-stigma-related variables entered in previous steps, thus supporting the trickle-down and progressive nature of the self-stigma model theorized.

CONCLUSIONS

Accounting for self-stigma in the assessment and treatment of individuals who stutter may identify and ultimately reduce environmental and personal barriers to communicative functioning and well-being in people who stutter. The self-stigma terminology and model described in this study will help practitioners, researchers, and the public better understand the process of self-stigma and how it may be associated with adverse outcomes experienced by people who stutter.

Stuttering management practices in Sri Lanka: A mixed method study

PURPOSE

Speech and language therapy is a growing profession in Sri Lanka, and little is known about how stuttering is currently managed in the country. Therefore, this study aimed to investigate the current stuttering management practices in Sri Lanka and to investigate any barriers to service provision.

METHOD

A convergent mixed methods design was employed across two phases. Sixty-four Sri Lankan speech and language therapists (SALTs) participated in online surveys in phase one and ten participated in semi structured interviews in phase two. Survey data in phase one was analysed using descriptive statistics and data in phase two was analysed using thematic analysis. Results from both phases were triangulated for the overall interpretation of the data.

RESULTS

Sri Lankan SALTs conduct a comprehensive assessment, however some assessment contexts (e.g., stuttering beyond the clinic) were not routinely considered. Speech and language therapists reported using multiple and varied intervention approaches/strategies, which were often adapted and/or combined. It was noted that the delivery of treatment was more challenging. Barriers identified were including limited knowledge of some aspects of stuttering management, limited access to resources, and workplace constraints.

CONCLUSION

Overall, findings revealed that most Sri Lankan SALTs employ a comprehensive and holistic approach in assessment; however, some limited knowledge of the disorder and intervention was identified. Findings highlighted the need for further training for SALTs regarding the management of stuttering, the need for culturally and linguistically validated appropriate assessments as well as the need to consider logistical issues in clinical settings and service delivery.

Intensive speech-language pathology therapy with adults who stutter: preliminary study

PURPOSE

To compare the results of fluency and self-perception of the impact of stuttering on the lives of adults who stutter, before and after undergoing intensive speech-language pathology therapy.

METHODS

This is a descriptive and longitudinal study with data collection before and after intensive therapy in four patients who stutter. The intensive care program consisted of thirty one-hour sessions held in five individual sessions a week. Speech samples collected before and after therapy were analyzed by two fluency experts. Descriptive data analysis was performed through the frequency distribution of categorical variables and analysis of measures of central tendency and dispersion of continuous variables. The verification of agreement between the evaluations carried out by the two judges was performed using the intraclass correlation coefficient (ICC). Correlation analysis was also performed using Spearman's rank correlation coefficient between the variables in the speech sample and the OASES-A scores.

RESULTS

There was a reduction of the percentage of stuttering disfluencies, increasing the flow of words per minute of the participants. The descriptive analysis of the OASES-A showed a decrease in the degree of impact of stuttering on the participants' lives in all parts of the questionnaire.

CONCLUSION

There was an improvement in all variables analyzed after intensive care, including an improvement in speech fluency and a reduction in the impact of stuttering on the participants' lives, which suggests the relevance of the intensive speech therapy proposal for stuttering.

The Effects of Written Stuttering Disclosure on the Perceptions of a Child Who Stutters

Purpose This study measured between-groups differences in perceived speech skills and personality characteristics of a 12-year-old male child who stutters (CWS) as a function of a written factual stuttering disclosure statement, delivered by the CWS, his "mother," or his "teacher." Method Four hundred twenty-four college-age adults were assigned to one of four groups, including three experimental groups (i.e., written self-disclosure, mother-written disclosure, and teacher-written disclosure) and a control group (no written disclosure). Participants in the control conditions viewed a brief video of the CWS. In the experimental conditions, participants read a brief written disclosure statement for 30 s, followed by the same video used in the control condition. After viewing the video, all participants completed surveys relative to their perceptions of the CWS speech skills and personality characteristics. Results Results reveal that a written stuttering disclosure statement provided by the mother correlated with select significant desirable perceptual differences of the CWS, while a written disclosure statement provided by the CWS yielded insignificant or even undesirable perceptual differences of the CWS. Written stuttering disclosures provided by a "teacher" did not yield any significant between-groups differences in the perception of a CWS. Gender affiliation was found to be a source of covariance in a number of perceived speech skills and personality characteristics. Conclusions Written stuttering disclosure statements provided by the "mother" correlated with select favorable perceptual differences of speech skills and personal characteristics of a CWS. Clinically, the application of novel methods (written and oral disclosure statements) and sources (i.e., CWS advocates such as "mother" and "teacher") of stuttering disclosure statement can be integrated into a systematic therapeutic program, creating an innovative approach of scaffolding self-advocacy via stuttering disclosure in CWS. Supplemental Material https://doi.org/10.23641/asha.15505857.

Intensive Stuttering Therapy with Telepractice Follow-Up: Longitudinal Outcomes

PURPOSE

This study estimated the treatment outcomes of a behavioral stuttering therapy program that blended a combination of intensive face-to-face therapy with telepractice-based follow-up therapy.

METHOD

A total of 17 participants (mean age = 22 years) who stutter participated in the program, preceded by an extended baseline period. The participants completed a series of assessments conducted over multiple time points, spanning a total of 42 weeks. Growth curve modeling was used to analyze the changes participants experienced in the frequency of stuttering, stuttering severity, communication attitudes, and quality of life.

RESULTS

The participants demonstrated stability throughout the extended baseline period, and experienced positive outcomes from the intensive program and the gains in communication attitudes and quality of life were largely maintained with weekly follow-up telepractice sessions. However, stuttering frequency and severity increased when the telepractice follow-up session frequency transitioned to a biweekly basis. Neither gender nor age group predicted the treatment outcomes for frequency or severity of stuttering. Gender-based differences were found for the treatment outcomes of specific self-report measures, with male participants having demonstrated a greater proportional decline on their standard scores, relative to female participants. Outcomes were similar for both adolescents and adults.

CONCLUSIONS

Participants attending the intensive stuttering therapy program experienced positive and significant changes in their speech, attitudes toward communication, and overall quality of life, which were maintained over time with structured, weekly telepractice follow-up sessions.

Life partners' perceptions of the emotional, speech disruptive, and attitudinal correlates of stuttering

PURPOSE

The purpose of the current investigation was to explore the extent to which the life partners (LPs) of people who stutter (PWS) perceive their loved ones' speech-situation specific emotional reaction, expectancy of speech disruption, and speech-related communication attitude.

METHODS

Three subtests of the Behavior Assessment Battery (BAB): the Speech Situation Checklist - Emotional Reaction (SSC-ER), the Speech Situation Checklist - Speech Disruption (SSC-SD) and the Communication Attitude Test for Adults Who Stutter (BigCAT) were administered to 33 PWS and modified versions were administered to their LPs via Qualtrics Survey Software. Effect of relationship duration on subtest scores was considered. Perceived stuttering severity by the participant and their LP was also queried as part of a demographic questionnaire.

RESULTS

PWS and their LPs rated BigCAT items in a similar way, while they rated certain SSC-ER and SSC-SD items differently. Importantly, between-group agreement was not affected by relationship duration. Among the PWS and LP, perceived stuttering severity influenced all BAB subtest scores.

CONCLUSION

LPs of PWS appear to be in tune with the cognitive aspects of their partner's experience of stuttering. This has important clinical implications as it relates to active involvement of the family in speech intervention targeting fluency.

Speech and Anxiety Management With Persistent Stuttering: Current Status and Essential Research

Purpose The purpose of this review article is to provide an overview of the current evidence base for the behavioral management of stuttering and associated social anxiety. Method We overview recent research about stuttering and social anxiety in the context of contemporary cognitive models of social anxiety disorder. That emerging evidence for self-focused attention and safety behavior use with those who stutter is considered in relation to current treatment approaches for stuttering: speech restructuring and social anxiety management. Results The emerging information about social anxiety and stuttering suggests a conflict between the two clinical approaches. For those clients who wish to control their stuttering and where speech restructuring is deemed the most suitable approach, it is possible that speech restructuring may (a) induce or increase self-focused attention, (b) promote the use of safety behaviors, and (c) become a safety behavior itself. This conflict needs to be explored further within clinical and research contexts. Conclusions The issues raised in this review article are complex. It appears that evidence-based speech treatment procedures are in conflict with current best-practice treatment procedures that deal with social anxiety. In this review article, we propose directions for future research to inform the development of improved treatments for those who stutter and recommendations for interim clinical management of stuttering.

A descriptive analysis of assessment measures on the effectiveness of a comprehensive stuttering intervention approach: A single case study

BACKGROUND

For effective client outcomes, stuttering assessment and intervention approaches need to be aligned. This encompasses using assessment and intervention approaches that address the three multidimensional constructs of stuttering, namely core behaviours, secondary behaviours and negative feelings and attitudes.

OBJECTIVE

The study aimed to explore whether multiple assessment measures could be used to describe the effectiveness of a comprehensive stuttering intervention approach, undergirded by the International Classification of Functioning, Disability and Health (ICF) framework.

METHOD

A single-subject case design was employed with one male adult who stutters. Data was collected by administering the Stuttering Severity Instrument-Fourth Edition (SSI-4) and Overall Assessment of the Speaker's Experience of Stuttering-Adults (OASES-A) at three testing periods (pre-intervention, immediately post-intervention and 7 months post-intervention), and a semi-structured interview schedule immediately post-intervention. Descriptive statistics was used to analyse the SSI-4 and OASES-A, and thematic analysis was conducted to evaluate the participant's interview schedule responses.

RESULTS

The participant's total scores, impact scores and severity ratings of both the SSI-4 and OASES decreased across the three testing periods. The main theme of effectiveness of the comprehensive stuttering intervention to reduce aspects of disability emerged from the participant's responses.

CONCLUSION

Evaluation of the results from the assessment measures revealed that the comprehensive stuttering intervention approach was effective in reducing the participant's core behaviours, secondary behaviours and negative feelings and attitudes. Assessment and management of fluency disorders should promote a client-specific multidimensional approach that extends beyond the core behaviours and secondary behaviours, by addressing the underlying social and emotional facets of fluency disorders.

Effects of Social Stress on Autonomic, Behavioral, and Acoustic Parameters in Adults Who Stutter

Purpose The purpose of this study was to assess changes in autonomic, behavioral, and acoustic measures in response to social stress in adults who stutter (AWS) compared to adults who do not stutter (ANS). Method Participants completed the State-Trait Anxiety Inventory ( Speilberger, Gorsuch, Luschene, Vagg, & Jacobs, 1983 ). In order to provoke social stress, participants were required to complete a modified version of the Trier Social Stress Test (TSST-M, Kirschbaum, Pirke, & Hellhammer, 1993 ), which included completing a nonword reading task and then preparing and delivering a speech to what was perceived as a group of professionals trained in public speaking. Autonomic nervous system changes were assessed by measuring skin conductance levels, heart rate, and respiratory sinus arrhythmia (RSA). Behavioral changes during speech production were measured in errors, percentage of syllable stuttered, percentage of other disfluencies, and speaking rate. Acoustic changes were measured using 2nd formant frequency fluctuations. In order to make comparisons of speech with and without social-cognitive stress, measurements were collected while participants completed a speaking task before and during TSST-M conditions. Results AWS showed significantly higher levels of self-reported state and trait anxiety compared to ANS. Autonomic nervous system changes revealed similar skin conductance level and heart rate across pre-TSST-M and TSST-M conditions; however, RSA levels were significantly higher in AWS compared to ANS across conditions. There were no differences found between groups for speaking rate, fundamental frequency, and percentage of other disfluencies when speaking with or without social stress. However, acoustic analysis revealed higher levels of 2nd formant frequency fluctuations in the AWS compared to the controls under pre-TSST-M conditions, followed by a decline to a level that resembled controls when speaking under the TSST-M condition. Discussion Results suggest that AWS, compared to ANS, engage higher levels of parasympathetic control (i.e., RSA) during speaking, regardless of stress level. Higher levels of self-reported state and trait anxiety support this view point and suggest that anxiety may have an indirect role on articulatory variability in AWS.

Acquired Stuttering in Veterans of the Wars in Iraq and Afghanistan: The Role of Traumatic Brain Injury, Post-Traumatic Stress Disorder, and Medications

Introduction

Determine the association between acquired stuttering (AS), traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD) in a cohort of 309,675 U.S. Iraq and Afghanistan veterans. The secondary aim was to determine the association between AS and medication patterns for veterans in the sample.

Materials and Methods

Retrospective study using data from the Veterans Health Administration National Repository for veterans deployed in support of combat operations in Iraq and Afghanistan and who received Veterans Health Administration care in 2010 and 2011. We identified stuttering using ICD-9 codes to establish the association between AS, TBI, and PTSD, controlling for demographic characteristics and other comorbidities. Multivariable logistic regression was used to determine the association between comorbid conditions and potentially problematic medications associated with stuttering.

Results

Two hundred thirty-five veterans (0.08%) were diagnosed with AS in the cohort. There was the greater likelihood of an AS diagnosis for veterans with concomitant TBI and PTSD when compared with veterans without these diagnoses. Over 66% of those with stuttering were prescribed at least one medication that affected speech fluency (antidepressants, anxiolytics, and antiepileptic drugs) compared with 35% of those without AS.

Conclusion

Veterans with a comorbid diagnosis of TBI and PTSD were more likely to be diagnosed with AS AOR: 9.77 (95% CI = 6.93-13.78, p < 0.05) and more likely to have been prescribed medications known to affect speech production OR: 3.68 (95% CI = 2.81-4.82, p < 0.05). Clinicians treating veterans with these complex comorbid conditions should consider the impact of medications on speech fluency.

Stuttering Frequency, Speech Rate, Speech Naturalness, and Speech Effort During the Production of Voluntary Stuttering

PURPOSE

Voluntary stuttering techniques involve persons who stutter purposefully interjecting disfluencies into their speech. Little research has been conducted on the impact of these techniques on the speech pattern of persons who stutter. The present study examined whether changes in the frequency of voluntary stuttering accompanied changes in stuttering frequency, articulation rate, speech naturalness, and speech effort.

METHOD

In total, 12 persons who stutter aged 16-34 years participated. Participants read four 300-syllable passages during a control condition, and three voluntary stuttering conditions that involved attempting to produce purposeful, tension-free repetitions of initial sounds or syllables of a word for two or more repetitions (i.e., bouncing). The three voluntary stuttering conditions included bouncing on 5%, 10%, and 15% of syllables read. Friedman tests and follow-up Wilcoxon signed ranks tests were conducted for the statistical analyses.

RESULTS

Stuttering frequency, articulation rate, and speech naturalness were significantly different between the voluntary stuttering conditions. Speech effort did not differ between the voluntary stuttering conditions. Stuttering frequency was significantly lower during the three voluntary stuttering conditions compared to the control condition, and speech effort was significantly lower during two of the three voluntary stuttering conditions compared to the control condition.

CONCLUSIONS

Due to changes in articulation rate across the voluntary stuttering conditions, it is difficult to conclude, as has been suggested previously, that voluntary stuttering is the reason for stuttering reductions found when using voluntary stuttering techniques. Additionally, future investigations should examine different types of voluntary stuttering over an extended period of time to determine their impact on stuttering frequency, speech rate, speech naturalness, and speech effort.

Exposure therapy for social anxiety disorder in people who stutter: An exploratory multiple baseline design

BACKGROUND & OBJECTIVES

Social anxiety disorder (SAD) is a debilitating condition, and approximately half of adults who stutter have SAD. Cognitive-behavioral therapy (CBT) has shown promise in decreasing social anxiety symptoms among adults who stutter, but exposure, arguably the essential component for successful CBT for SAD, has been understudied and underemphasized. Aims of this study were to develop an exposure therapy protocol designed specifically for people who stutter and have SAD and evaluate its potential efficacy in reducing social anxiety and stuttering severity using a multiple baseline design.

METHODS

Six participants received ten sessions of exposure therapy. Participants reported daily social anxiety, and social distress and stuttering severity were evaluated at major assessment points.

RESULTS

There were substantial reductions in social anxiety and considerable improvements in affective, behavioral, and cognitive experiences of stuttering. No consistent change was observed for stuttering frequency. Gains were mostly maintained after six-months.

CONCLUSIONS

Results suggest that the novel exposure approach may decrease social distress, but not necessarily influence speech fluency. These findings underscore the importance of the assessment and treatment of SAD among adults who stutter and suggest that the integration of care between clinical psychologists and speech-language pathologists may prove beneficial for this population.

The Satisfaction with Communication in Everyday Speaking Situations (SCESS) scale: An overarching outcome measure of treatment effect

PURPOSE

The Consolidated Standards of Reporting Trials (CONSORT) statement strongly suggests one primary outcome for clinical trials, yet the outcomes of stuttering treatments span numerous behavioral and psychosocial domains. That presents a roadblock to eventual meta-analysis of clinical trials for adults who stutter.

METHOD

We propose a simple and convenient outcome measure for clinical trials of stuttering treatment for adults that spans whatever behavioral and psychosocial factors might impel clients to seek treatment: a nine-point scale of Satisfaction with Communication in Everyday Speaking Situations (SCESS). The scale consists of one question which is simple, brief, easy to administer, cost-free, and translatable into many languages. The present report develops the SCESS scale by determining its reliability, content validity, and construct validity.

RESULTS

Reliability, content validity, and construct validity of the SCESS were confirmed with statistically significant and substantive correlations with speech-related and anxiety-related measures. However, the SCESS did not correlate well with percentage syllables stuttered. Three behavioral and psychosocial measures had the highest correlation with the SCESS: total Overall Assessment of the Speaker's Experience of Stuttering, self-reported stuttering severity, and Unhelpful Thoughts and Beliefs about Stuttering.

CONCLUSION

The SCESS measure has potential to be applied as an overarching clinical trial outcome measure of stuttering treatment effect. This study provides some preliminary evidence for including it as a primary or secondary outcome in clinical trials of adult stuttering treatments. However, further studies are needed to establish the SCESS responsiveness to different stuttering treatments.

Speech Language Pathology Rehabilitation

The speech language pathologist has a vital management role in patients with voice and swallow concerns, as well as stroke patients and patients with fluency problems. This article summarizes the variety of speech and swallow rehabilitation that adult patients may require or seek. The case examples allow the reader to base the clinical decision-making process within the context of a patient presentation and elucidate the role of speech and language pathology services for the primary care provider in order to refer patients with symptoms and concerns to the right provider early in their medical care.

We Have a Voice: Exploring Participants' Experiences of Stuttering Modification Therapy

PURPOSE

Qualitative data were obtained from 8 people who stutter about their experiences and changes they perceived following attendance of an intensive group therapy intervention. Measures that related to reductions in stuttering, improved communicative confidence, and impacts on stuttering and quality of life were used to complement the qualitative data.

METHOD

Eight participants attended a group stuttering modification course for adults who stutter. They reported their experiences of therapy and perceived changes in a focus group immediately after therapy and at a semistructured interview 6 months post-therapy. Participants completed 5 additional quantitative standardized outcome measures at 3 data collection points (before and directly after therapy and 6 months post-therapy). These measures provided information about stuttering severity and frequency, use of avoidance strategies, attitude change, communicative confidence, quality of life, and locus of control.

RESULTS

Thematic analysis of the qualitative data identified 4 main areas: thoughts, feelings, and behaviors before therapy and motivation for seeking therapy; direct experience of the course; learning outcomes and challenges and solutions for maintaining change; and ways in which attending therapy had made a difference. These reported changes were supported by the quantitative measures that demonstrated improved communicative confidence; increased self-awareness; affective, behavioral, and cognitive changes; reduced use of avoidance strategies; and lower impact of stuttering on quality of life.

CONCLUSIONS

The qualitative analyses confirmed positive speech and attitude changes consequent on participants' attendance at stuttering modification therapy. These changes, further corroborated by quantitative measures, were linked to reports of improved quality of life. Further research is required to investigate the effectiveness of this form of therapy empirically and from the client's perspective.

Adults who stutter lack the specialised pre-speech facilitation found in non-stutterers

OBJECTIVES

Persistent developmental stuttering is a speech fluency disorder defined by its symptoms, where the underlying neurophysiological causes remain uncertain. This study examined the underlying neurophysiological mechanisms of the speech planning process, using facilitation in the motor cortex during speech preparation as an analogue.

METHODS

transcranial magnetic stimulation (TMS) pulses induced motor evoked potentials (MEPs), which were recorded from the tongue. Eighteen adults who stutter (AWS) and 17 adults who do not stutter (ANS) completed three experiments, which involved reading a German prefix+verb utterance from a screen. Each experiment involved 120 trials with three distinct levels of speech production: immediate speech, delayed speech without pacing and delayed speech with predefined pacing. TMS was applied shortly before speech onset. Trial MEPs were normalised to average non-speech MEPs. MEP amplitude, MEP facilitation ratio (amplitude: pre-speech offset) and group difference were the outcomes of interest analysed by multiple regression, as well as speech reaction time analysed by correlation.

RESULTS

MEP values were 11·1%-23·4% lower in AWS than ANS (by standardised Beta), across all three experiments. MEP facilitation ratio slopes were also 4·9%-18·3% flatter in AWS than ANS across all three experiments. Reaction times for AWS were only significantly slower than for ANS in immediate speech and predefined pacing experiments. No stuttering was detected during the trials. The group difference in immediate speech was 100% and 101% greater than the other two experiments respectively.

DISCUSSION

While performance of both ANS and AWS worsens under disturbed speech conditions, greater disturbance conditions affected controls worse than AWS. Future research and therapy in stuttering should focus on non-disturbed speech.

Comprehensive Stuttering Treatment for Adolescents: A Case Study

Purpose

This article will focus on a hypothetical case study to highlight comprehensive assessment and treatment for adolescent children who stutter.

Method

Assessment and treatment are laid out with a literature review utilizing the components of the International Classification of Functioning, Disability and Health model. Specific assessment and treatment strategies and approaches are discussed.

Results

Using the International Classification of Functioning, Disability and Health model can help guide clinicians through the assessment and treatment process to ensure that all areas of stuttering are considered.

Conclusion

Comprehensive assessment and treatment helps clinicians address all relevant elements of a stuttering disorder, rather than focusing exclusively on reducing speech disruptions.

Evidence, Goals, and Outcomes in Stuttering Treatment: Applications With an Adolescent Who Stutters

Purpose

The purpose of this clinical focus article is to summarize 1 possible process that a clinician might follow in designing and conducting a treatment program with John, a 14-year-old male individual who stutters.

Method

The available research evidence, practitioner experience, and consideration of individual preferences are combined to address goals, treatment procedures, and outcomes for John.

Conclusions

The stuttering treatment research literature includes multiple well-designed reviews and individual studies that have shown the effectiveness of prolonged speech (and smooth speech and related variations) for improving stuttered speech and for improving social, emotional, cognitive, and related variables in adolescents who stutter. Based on that evidence, and incorporating the additional elements of practitioner experience and client preferences, this clinical focus article suggests that John would be likely to benefit from a treatment program based on prolonged speech. The basic structure of 1 possible such program is also described, with an emphasis on the goals and outcomes that John could be expected to achieve.

The experience of stuttering among Ultra-Orthodox and Secular/Traditional Jews

PURPOSE

This groundbreaking research compares the experience of stuttering among adult male People Who Stutter (PWS) from the ultra-Orthodox (UO) Jewish community in Israel to those from Secular/Traditional (ST) backgrounds.

METHODS

Participants were 32 UO and 31 ST PWS, aged 18-67 years. Self-report questionnaires utilized: Perceived Stuttering Severity (PSS); Overall Assessment of the Speaker's Experience of Stuttering (OASES-A); Students' Life Satisfaction Scale (SLSS); Situation Avoidance Behavior Checklist (SABC). Demographic, religious, and stuttering information was collected. Groups were compared on scales, and correlations between scales and the PSS.

RESULTS

Subjective stuttering severity ratings were significantly higher among the UO. A significant group effect was found for the OASES-A quality of life subscale, but not other subscales. Significant positive correlations were found between: 1) PSS and OASES-A Total Impact; 2) PSS and 3 OASES subscales; and 3) PSS and SABC (indicating increased avoidance with increased stuttering severity rating). A significant negative correlation was found between the PSS and SLSS, indicating lower life satisfaction with higher rates of stuttering severity among the ST. Interestingly, when tested by group, significant correlations between the PSS and all other study measures were observed only among the ST.

CONCLUSION

UO participants showed higher subjective stuttering severity ratings, yet less impact on quality of life, and no correlation between subjective stuttering and other measures of stuttering experience. These novel findings may result from the combined protective effect of religiosity and socio-cultural characteristics on UO PWS' well-being, despite heightened concern about social consequences of stuttering within UO society.

The effects of actors vocal exercises for relaxation on fluency: A preliminary study

PURPOSE

To determine the efficacy of treatment based on Kristin Linklater's technique for vocal preparation for performance for use with people who stutter.

METHOD

A protocol for a treatment for stuttering involving breathing exercises, relaxation techniques, and focus on awareness was designed by the first author from Linklater's published exercises in her book Freeing the Natural Voice (2006). Four adults who stutter participated in a 12-week, single-case reversal design study. Treatment efficacy was determined by baseline and post-treatment measures on the OASES, self-report naturalness, tension and severity scale, and percentage of stuttering-like disfluency (SLD). Qualitative measures included a daily tension and practice log, a program completion questionnaire, and accounts from the clinicians administering the treatment protocol.

RESULTS

Three of four participants scored lower on the OASES post-treatment, suggesting that the impact of stuttering on their daily lives had decreased. All four experienced a reduction in the number of SLD counted throughout treatment sessions compared to baseline data.

CONCLUSION

A treatment for stuttering based on Linklater's work including regulation of breathing, relaxation, and awareness of breath may be effective in improving fluency and decreasing the impact of stuttering and warrants further study.

Discrimination and internalised feelings experienced by people who stutter in Jordan

PURPOSE

This study investigated the internalised feelings and discrimination experienced by people who stutter in Jordan.

METHOD

Five adult speakers who stutter were interviewed as a focus group. The participants were asked about their feelings related to stuttering and discrimination. The participants' responses in the focus group and items adapted from the extant literature formed the basis of a 20-item questionnaire. The questionnaire was administered to 20 additional adults who stutter to assess their internalised feelings about stuttering and their perceived rejecting behaviours (discrimination) associated with their impairment.

RESULT

Feeling "annoyed" was the item that received the highest percentage of negative internalised feelings, followed by "embarrassed," "shame," "disappointed," "nervous, "sad," "pessimistic," "fearful," "worried" and "lonely." The results of the discrimination experiences indicated that "getting a leadership position" was the item that most people who stutter reported being worried about, followed by "participation in the classroom," "getting a job," "getting married," "being fully paid in their jobs," "teased," "promoted" and "renting a house."

CONCLUSION

These findings provide further evidence of the universality that stuttering is more than the core surface features of speech, but also include aspects that exist below the surface such as negative internalised feelings and various discrimination experiences.

The relationship between the experience of stuttering and demographic characteristics of adults who stutter

PURPOSE

This study aims to examine the association between adults' experience of stuttering and their age, gender and marital status, as well as to evaluate the psychometric properties of the Hebrew version of the OASES-A.

METHODS

The Hebrew version of the OASES-A was administered to 91 adults-who-stutter. The validity of the translated version was evaluated using a subset of 43 participants, who also completed three additional instruments: (a) a Perceived Stuttering Severity (PSS) self-rating scale, (b) the Situation Avoidance Behavior Checklist (SABC), (c) the Students Life Satisfaction scale (SLSS). Finally, the correlations between the participants' OASES-A scores and their age, gender and marital status were calculated.

RESULTS

A negative correlation was found between the participants' OASES-A impact scores and their age (p<0.01). In addition, married participants exhibited lower OASES-A impact scores compared with unmarried participants (p<0.05). On the other hand, the speakers' gender was not associated with OASES-A impact scores.

RESULTS

revealed high internal consistency of the Hebrew OASES-A, and moderate to strong correlations with the additional examined instruments. Finally, results of the Hebrew version of the questionnaire were comparable with those obtained in other languages.

CONCLUSION

Our results indicated that, within our cohort, age and marital status are significantly associated with the personal experience of stuttering, whereas gender is not. In addition, the Hebrew version of the OASES-A is valid and comparable with equivalent versions in other languages. This facilitates the application of the OASES-A in future clinical and research settings.

Utility of virtual reality environments to examine physiological reactivity and subjective distress in adults who stutter

PURPOSE

Virtual reality environments (VREs) allow for immersion in speaking environments that mimic real-life interactions while maintaining researcher control. VREs have been used successfully to engender arousal in other disorders. The purpose of this study was to investigate the utility of virtual reality environments to examine physiological reactivity and subjective ratings of distress in persons who stutter (PWS).

METHOD

Subjective and objective measures of arousal were collected from 10PWS during four-minute speeches to a virtual audience and to a virtual empty room.

RESULTS

Stuttering frequency and physiological measures (skin conductance level and heart rate) did not differ across speaking conditions, but subjective ratings of distress were significantly higher in the virtual audience condition compared to the virtual empty room.

CONCLUSION

VREs have utility in elevating subjective ratings of distress in PWS. VREs have the potential to be useful tools for practicing treatment targets in a safe, controlled, and systematic manner.

Communication restriction in adults who stutter: Part III

This is the third article in a series examining communication restriction in adults with stuttering (AWS). The aim was to explore interpersonal communication behaviour in AWS at long-term treatment follow-up, using systemic functional linguistics (SFL) as an analytical framework. The performance of 10 AWS within 10-minute conversation samples was compared across pretreatment (T1), post-treatment (T2), and 12-month follow-up (T3), in terms of language productivity and complexity, modality, and appraisal. At T1 and T3, comparisons were also made to a control group (AWNS). Post-treatment increases in (1) language complexity, (2) frequency of modal operators, and (3) expression of appraisal were maintained in the AWS group at T3. No significant differences in these areas were found between AWS and AWNS at T3. The findings suggest that intensive comprehensive stuttering treatment can affect lasting functional change in interpersonal language use for AWS.

Premonitory Awareness in Stuttering Scale (PAiS)

Anticipation of stuttering events in persistent developmental stuttering is a frequent but inadequately measured phenomenon that is of both theoretical and clinical importance. Here, we describe the development and preliminary testing of a German version of the Premonitory Awareness in Stuttering Scale (PAiS): a 12-item questionnaire assessing immediate and prospective anticipation of stuttering that was translated and adapted from the Premonitory Urge for Tics Scale (PUTS) (Woods, Piacentini, Himle, & Chang, 2005). After refining the preliminary PAiS scale in a pilot study, we administered a revised version to 21 adults who stutter (AWS) and 21 age, gender and education-matched control participants. Results demonstrated that the PAiS had good internal consistency and discriminated the two speaker groups very effectively, with AWS reporting anticipation of speech disruptions significantly more often than adults with typical speech. Correlations between the PAiS total score and both the objective and subjective measures of stuttering severity revealed that AWS with high PAiS scores produced fewer stuttered syllables. This is possibly because these individuals are better able to adaptively use these anticipatory sensations to modulate their speech. These results suggest that, with continued refinement, the PAiS has the potential to provide clinicians and researchers with a practical and psychometrically sound tool that can quantify how a given AWS anticipates upcoming stuttering events.

Non-pharmacological treatments for stuttering in children and adults: a systematic review and evaluation of clinical effectiveness, and exploration of barriers to successful outcomes

BACKGROUND

Despite many years of research, there is no certainty regarding the cause of stuttering. Although numerous interventions have been developed, a broad-based systematic review across all forms of intervention for adults and children was needed including views and perceptions of people who stutter.

OBJECTIVE

The aims of the study were to report the clinical effectiveness of interventions for people who stutter (or clutter), to examine evidence regarding the views of people who stutter and the views of professionals regarding interventions.

DATA SOURCES

A systematic review of quantitative and qualitative literature was carried out between August 2013 and April 2014. The following electronic databases were searched: (1) MEDLINE, (2) EMBASE, (3) The Cochrane Library (including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database and NHS Economic Evaluations Database), (4) PsycINFO, (5) Science Citation Index, (6) Social Science Citation Index, (7) Cumulative Index to Nursing and Allied Health Literature, (8) ASSIA, (9) Linguistics and Language Behavior Abstracts, (10) Sociological Abstracts and (11) the EPPI Centre. Reference lists of included papers and other reviews were screened and also key journals in the subject area were hand-searched.

REVIEW METHODS

The searches aimed to identify (1) evidence of clinical effectiveness in populations of pre-school children, school-aged children, adolescents and adults, and (2) data relating to perceptions of barriers and facilitators to intervention clinical effectiveness among staff and people who stutter. A metasynthesis of the two linked elements via development of a conceptual model was also carried out to provide further interpretation of the review findings.

RESULTS

A systematic search of the literature identified a large number of potentially relevant studies. Of these, 111 studies examining the clinical effectiveness of interventions, 25 qualitative papers and one mixed-methods paper met the criteria for inclusion in this review. Review of the effectiveness literature indicated evidence of positive outcomes across all types of interventions. Virtually all evidence we identified reported at least some positive effect for some participants. However, there was evidence of considerable individual variation in outcome for study participants. The qualitative literature highlighted the need for programmes to be tailored to individual need with variation at the levels of the intervention, the individual and interpersonal/social elements. Metasynthesis of the data highlighted the complexity of elements that need to be considered in evaluation of long-term impacts following stuttering interventions.

LIMITATIONS

Around two-thirds of the studies were considered to be at higher risk of bias. The heterogeneous nature and variability in outcomes meant that we were unable to complete a meta-analysis.

CONCLUSIONS

Although much of the evidence we identified was from studies at risk of bias, it is suggested that most available interventions for stuttering may be of benefit to at least some people who stutter. There is a requirement for greater clarity regarding what the core outcomes following stuttering intervention should be and also enhanced understanding of the process whereby interventions effect change. Further analysis of those for whom interventions have not produced a significant benefit may provide additional insights into the complex intervention-outcomes pathway.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004861.

The Client's Perspective on Voluntary Stuttering

PURPOSE

Voluntary stuttering is a strategy that has been suggested for use in the clinical literature but has minimal empirical data regarding treatment outcomes. The purpose of the present study is to explore client perspectives regarding the impact of the use of this strategy on the affective, behavioral, and cognitive components of stuttering.

METHOD

The present study used an original survey designed to explore the intended purpose. A total of 206 adults who stutter were included in the final data corpus. Responses were considered with respect to the type of voluntary stuttering the participants reportedly produced and the location of use.

RESULTS

A client perceives significantly greater affective, behavioral, and cognitive benefits from voluntary stuttering when the production is closely matched to the client's actual stutter and when it is used outside the clinical environment.

CONCLUSIONS

To enhance client perception of associated benefits, clinicians should encourage use of voluntary stuttering that closely matches the client's own stuttering. Clinicians should also facilitate practice of voluntary stuttering outside of the therapy room. Finally, clinicians should be aware that clients, at least initially, may not perceive any benefits from the use of this strategy.

Communication restriction in adults who stutter: Part II

This article presents a follow-up study to Lee, van Dulm, Robb, and Ormond (2015). The aim was to explore communication restriction in adults with stuttering (AWS) using typical language measures and systemic functional linguistics (SFL) analyses. The article compared the pre- and post-treatment performance of AWS in language productivity and complexity, transitivity, modality, appraisal, and theme. Ten-minute conversational samples were obtained from 20 AWS before and after participation in intensive stuttering treatment. Transcripts were analysed for quantity and complexity of verbal output, and frequency of transitivity, modality, appraisal and theme resources. Between pre- and post-treatment, the following differences were observed: (1) a significant increase in frequency of modal operators, and trends approaching significance for (2) increased language complexity (3) increased language expressing appraisal. These changes suggest increased flexibility of language use in AWS following treatment, particularly towards interpersonal engagement. The value of SFL to this area of research is discussed.

A Research-Based Clinical Tutorial in Adolescent Stuttering: Response to Coleman, Miller, and Weidner (2015)

Coleman, Miller, and Weidner's (2015) recent clinical vignette and tutorial described one very common, broad-based, and theory-driven approach to treating stuttering in a 14-year-old boy. This response suggests that methods based on prolonged speech are better supported in our research literature; are effective, efficient, and well-received by clients; and allow clinicians using the principles of evidence-based practice to address and solve the concerns that clients have raised.

The state of the art in non-pharmacological interventions for developmental stuttering. Part 1: a systematic review of effectiveness

BACKGROUND

The growing range of available treatment options for people who stutter presents a challenge for clinicians, service managers and commissioners, who need to have access to the best available treatment evidence to guide them in providing the most appropriate interventions. While a number of reviews of interventions for specific populations or a specific type of intervention have been carried out, a broad-based systematic review across all forms of intervention for adults and children was needed to provide evidence to underpin future guidelines, inform the implementation of effective treatments and identify future research priorities.

AIMS

To identify and synthesize the published research evidence on the clinical effectiveness of the broad range of non-pharmacological interventions for the management of developmental stuttering.

METHODS & PROCEDURES

A systematic review of the literature reporting interventions for developmental stuttering was carried out between August 2013 and April 2014. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for the identification of relevant studies included electronic database searching, reference list checking, citation searching and hand searching of key journals. Appraisal of study quality was performed using a tool based on established criteria for considering risk of bias. Due to heterogeneity in intervention content and outcomes, a narrative synthesis was completed.

MAIN CONTRIBUTION

The review included all available types of intervention and found that most may be of benefit to at least some people who stutter. There was evidence, however, of considerable individual variation in response to these interventions. The review indicated that effects could be maintained following all types of interventions (although this was weakest with regard to feedback and technology interventions).

CONCLUSIONS

This review highlights a need for greater consensus with regard to the key outcomes used to evaluate stuttering interventions, and also a need for enhanced understanding of the process whereby interventions effect change. Further analysis of the variation in effectiveness for different individuals or groups is needed in order to identify who may benefit most from which intervention.

A standalone Internet cognitive behavior therapy treatment for social anxiety in adults who stutter: CBTpsych

PURPOSE

Social anxiety is common for those who stutter and efficacious cognitive behavior therapy (CBT) for them appears viable. However, there are difficulties with provision of CBT services for anxiety among those who stutter. Standalone Internet CBT treatment is a potential solution to those problems. CBTpsych is a fully automated, online social anxiety intervention for those who stutter. This report is a Phase I trial of CBTpsych.

METHOD

Fourteen participants were allowed 5 months to complete seven sections of CBTpsych. Pre-treatment and post-treatment assessments tested for social anxiety, common unhelpful thoughts related to stuttering, quality of life and stuttering frequency.

RESULTS

Significant post-treatment improvements in social anxiety, unhelpful thoughts, and quality of life were reported. Five of seven participants diagnosed with social anxiety lost those diagnoses at post-treatment. The two participants who did not lose social anxiety diagnoses did not complete all the CBTpsych modules. CBTpsych did not improve stuttering frequency. Eleven of the fourteen participants who began treatment completed Section 4 or more of the CBTpsych intervention.

CONCLUSIONS

CBTpsych provides a potential means to provide CBT treatment for social anxiety associated with stuttering, to any client without cost, regardless of location. Further clinical trials are warranted.

EDUCATIONAL OBJECTIVES

At the end of this activity the reader will be able to: (a) describe that social anxiety is common in those who stutter; (b) discuss the origin of social anxiety and the associated link with bullying; (c) summarize the problems in provision of effective evidence based cognitive behavior therapy for adults who stutter; (d) describe a scalable computerized treatment designed to tackle the service provision gap; (e) describe the unhelpful thoughts associated with stuttering that this fully automated computer program was able to tackle; (f) list the positive outcomes for individuals who stuttered that participated in this trial such as the reduction of social anxiety symptoms and improvement in the quality of life for individuals who stuttered and participated in this trial.

Anxiety of children and adolescents who stutter: a review

PURPOSE

Adults who stutter have heightened rates of anxiety disorders, particularly social anxiety disorder, compared with non-stuttering controls. However, the timing of anxiety onset and its development in relation to stuttering is poorly understood. Identifying the typical age of anxiety onset in stuttering has significant clinical implications and is crucial for the management of both disorders across the lifespan. The present review aims to determine the scope of the research pertaining to this topic, identify trends in findings, and delineate timing of anxiety onset in stuttering.

METHODS

We examine putative risk factors of anxiety present for children and adolescents who stutter, and provide a review of the research evidence relating to anxiety for this population.

RESULTS

Young people who stutter can experience negative social consequences and negative attitudes towards communication, which is hypothesised to place them at increased risk of developing anxiety. The prevalence of anxiety of young people who stutter, and the timing of anxiety onset in stuttering could not be determined. This was due to methodological limitations in the reviewed research such as small participant numbers, and the use of measures that lack sensitivity to identify anxiety in the targeted population.

CONCLUSIONS

In sum, the evidence suggests that anxiety in stuttering might increase over time until it exceeds normal limits in adolescence and adulthood. The clinical implications of these findings, and recommendations for future research, are discussed.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) discuss contemporary thinking on the role of anxiety in stuttering and reasons for this view; (b) describe risk factors for the development of anxiety in stuttering, experienced by children and adolescents who stutter (c) outline trends in current research on anxiety and children and adolescents with stuttering; and (d) summarise rationales behind recommendations for future research in this area.

Stuttering in relation to anxiety, temperament, and personality: review and analysis with focus on causality

Anxiety and emotional reactions have a central role in many theories of stuttering, for example that persons who stutter would tend to have an emotionally sensitive temperament. The possible relation between stuttering and certain traits of temperament or personality were reviewed and analyzed, with focus on temporal relations (i.e., what comes first). It was consistently found that preschool children who stutter (as a group) do not show any tendencies toward elevated temperamental traits of shyness or social anxiety compared with children who do not stutter. Significant group differences were, however, repeatedly reported for traits associated with inattention and hyperactivity/impulsivity, which is likely to reflect a subgroup of children who stutter. Available data is not consistent with the proposal that the risk for persistent stuttering is increased by an emotionally reactive temperament in children who stutter. Speech-related social anxiety develops in many cases of stuttering, before adulthood. Reduction of social anxiety in adults who stutter does not in itself appear to result in significant improvement of speech fluency. Studies have not revealed any relation between the severity of the motor symptoms of stuttering and temperamental traits. It is proposed that situational variability of stuttering, related to social complexity, is an effect of interference from social cognition and not directly from the emotions of social anxiety. In summary, the studies in this review provide strong evidence that persons who stutter are not characterized by constitutional traits of anxiety or similar constructs.

EDUCATIONAL OBJECTIVES

This paper provides a review and analysis of studies of anxiety, temperament, and personality, organized with the objective to clarify cause and effect relations. Readers will be able to (a) understand the importance of effect size and distribution of data for interpretation of group differences; (b) understand the role of temporal relations for interpretation of cause and effect; (c) discuss the results of studies of anxiety, temperament and personality in relation to stuttering; and (d) discuss situational variations of stuttering and the possible role of social cognition.

Social anxiety disorder and stuttering: current status and future directions

Anxiety is one of the most widely observed and extensively studied psychological concomitants of stuttering. Research conducted prior to the turn of the century produced evidence of heightened anxiety in people who stutter, yet findings were inconsistent and ambiguous. Failure to detect a clear and systematic relationship between anxiety and stuttering was attributed to methodological flaws, including use of small sample sizes and unidimensional measures of anxiety. More recent research, however, has generated far less equivocal findings when using social anxiety questionnaires and psychiatric diagnostic assessments in larger samples of people who stutter. In particular, a growing body of research has demonstrated an alarmingly high rate of social anxiety disorder among adults who stutter. Social anxiety disorder is a prevalent and chronic anxiety disorder characterised by significant fear of humiliation, embarrassment, and negative evaluation in social or performance-based situations. In light of the debilitating nature of social anxiety disorder, and the impact of stuttering on quality of life and personal functioning, collaboration between speech pathologists and psychologists is required to develop and implement comprehensive assessment and treatment programmes for social anxiety among people who stutter. This comprehensive approach has the potential to improve quality of life and engagement in everyday activities for people who stutter. Determining the prevalence of social anxiety disorder among children and adolescents who stutter is a critical line of future research. Further studies are also required to confirm the efficacy of Cognitive Behaviour Therapy in treating social anxiety disorder in stuttering.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) describe the nature and course of social anxiety disorder; (b) outline previous research regarding anxiety and stuttering, including features of social anxiety disorder; (c) summarise research findings regarding the diagnostic assessment of social anxiety disorder among people who stutter; (d) describe approaches for the assessment and treatment of social anxiety in stuttering, including the efficacy of Cognitive Behaviour Therapy; and (e) outline clinical implications and future directions associated with heightened social anxiety in stuttering.

Verbal implicit sequence learning in persons who stutter and persons with Parkinson's disease

The authors investigated the integrity of implicit learning systems in 14 persons with Parkinson's disease (PPD), 14 persons who stutter (PWS), and 14 control participants. In a 120-min session participants completed a verbal serial reaction time task, naming aloud 4 syllables in response to 4 visual stimuli. Unbeknownst to participants, the syllables formed a repeating 8-item sequence. PWS and PPD demonstrated slower reaction times for early but not late learning trials relative to controls reflecting delays but not deficiencies in general learning. PPD also demonstrated less accuracy in general learning relative to controls. All groups demonstrated similar limited explicit sequence knowledge. Both PWS and PPD demonstrated significantly less implicit sequence learning relative to controls, suggesting that stuttering may be associated with compromised functional integrity of the cortico-striato-thalamo-cortical loop.

Behavioral treatments for children and adults who stutter: a review

This paper provides a brief overview of stuttering followed by a synopsis of current approaches to treat stuttering in children and adults. Treatment is discussed in terms of multifactorial, operant, speech restructuring, and anxiolytic approaches. Multifactorial and operant treatments are designed for young children who stutter. Both of these approaches involve parent training and differ primarily in their focus on reducing demands on the child (multifactorial) or in their use of response contingent stimulation (operant conditioning). Speech restructuring and anxiolytic approaches are used with adults who stutter. Speech restructuring approaches focus on the mechanics of speech production, and anxiolytic treatments tend to focus on the symptoms and social and vocational challenges of stuttering. The evidence base for these different approaches is outlined. Response contingent therapy (for children) and speech restructuring therapy (for adults) have the most robust empirical evidence base. Multifactorial treatments for children and stuttering management approaches for adults are popular but are based on theoretical models of stuttering; the evidence base is not robust and tends to be inferred from work in areas such as cognitive behavior therapy and desensitization. Comprehensive, or holistic, approaches to treating stuttering are also discussed. Comprehensive approaches for treating stuttering in adults address both improved speech fluency and stuttering management.

Self-help conferences for people who stutter: a qualitative investigation

Self-help activities for people who stutter (PWS) have been gaining in popularity; however, there is a scarcity of evidence to support their utility in stuttering management. The purpose of this investigation was to understand the lived experience of individuals who attended a self-help conference(s) for PWS from the perspective of a PWS to learn its potential utility in stuttering management. The investigator used Interpretive Phenomenological Analysis (IPA) to systematically collect authentic data of this social phenomenon. Twelve participants were recruited from a self-help conference and the self-help community of PWS. Semi-structured interviews were conducted 4-18 months after each participant's last conference. Interviews were transcribed and analyzed. Themes were explained in investigator narratives and illustrated through participants' quotes. Interpreted themes of the experience of having attended a self-help conference(s) for PWS included: socializing opportunities with other PWS, affiliation, redefining oneself and post-conference disclosures. A conclusion of the study was that the experience of having attended a self-help conference(s) for PWS helped to minimize negative impact that stuttering can have on daily functioning. It appears that self-help conferences were perceived as a safer or "stutter-friendly" environment and promoted social interaction, relationship building, and community building through planned and unplanned activities. Another conclusion was that the experience of having attended self-help conferences for PWS helped participants to communicate more easily. Reported increases in social activity and an "openness" about stuttering, suggest self-help conferences' utility in stuttering management. These findings are supported by other studies about successful stuttering management and self-help activities for PWS. They have helped attendees who stutter to communicate more easily and suggest a reduction in the negative impact that stuttering has on their lives.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) describe recurring themes associated with the lived experience having attended a self-help conference(s) for people who stutter (PWS) from the perspective of a group of adults who stutter, and (2) describe the potential benefits of attending self-help conferences for PWS in order to make appropriate evidence-based referrals to self-help conferences for PWS.

Documenting changes in adult speakers' locus of causality during stuttering treatment using Origin and Pawn scaling

The concepts of locus of control and locus of causality are similar and refer to the degree to which a person perceives daily occurrences to be a consequence of his or her own behavior. Locus of control is considered to be a unidimensional construct indicating an inverse relationship between the polls of internality and externality. The locus of control is generally determined by using questionnaires with a limited number of items. Locus of causality is considered to be a two-dimensional construct where Origin and Pawn values, which are similar to internality and externality, respectively, are not necessarily inversely related. Locus of causality is determined by content analysis of freely spoken or written narratives. In the current study Origin and Pawn scores were obtained from twenty adults prior to and following a three-week intensive stuttering treatment program. Brief narratives written by the participants were analyzed to obtain Origin and Pawn values. These scores were compared with traditional measures of therapeutic outcome (Locus of Control, OASES, PSI, percentage of syllables stuttered). Results indicated statistically significant increases in pre- to post-treatment Origin scores (p=.001; Cohen's d=1.44) and statistically significant decreases in pre- to post-treatment Pawn scores (p=.003; Cohen's d=1.11). Origin and Pawn scores showed significant relationships with other measures of stuttering, indicating concurrent and construct validity. Origin and Pawn scaling procedures appear to provide a valid, sensitive, and nonreactive indicator of the speaker's locus of causality and ability to develop an autonomous and agentic lifestyle.

EDUCATIONAL OBJECTIVES

After reading this article, the readers will be able to: (1) distinguish between the concepts of locus of control and locus of causality, (2) describe the characteristics of individuals behaving as an Origin and a Pawn, (3) differentiate patterns of change for Origin and Pawn scores prior to and following treatment, and (4) describe the clinical advantages using Origin and Pawn scaling procedures for individuals who stutter.

The "Iowa Way" revisited

This paper attempts to bridge the gap between past and present stuttering therapy approaches. Specifically, the ideas and methods of Wendell Johnson and Dean Williams are compared to current approaches used in treating mental illness and communication disorders in which there is an emphasis on focusing on what is "right" with the individual and spending less time focusing on the "disorder". There is particular emphasis on tying Johnson's and Williams' overall philosophy to modern psychological approaches rooted in "Positive Psychology", to highlight how these early ideas in stuttering therapy may help us to discover the common factors that underlie the success of several different stuttering therapy approaches, independent of the specific techniques employed. It is proposed that future research on clinical efficacy in stuttering should use focused hypotheses techniques to investigate common factors that make therapy effective across individuals and therapy approaches.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) summarize the basic philosophy of the "Iowa" approach to stuttering as laid out by Wendell Johnson and Dean Williams; (2) describe current therapeutic techniques that incorporate "positive psychology"; (3) discuss possible common factors that influence therapy outcome that are independent of the therapeutic technique employed.

Anxiety and stuttering: continuing to explore a complex relationship

PURPOSE

The relationship between anxiety and stuttering has been widely studied. However, a review conducted more than 10 years ago (Menzies, Onslow, & Packman, 1999) identified 5 methodological issues thought to preclude consistent research findings regarding the nature of this relationship. The purpose of the present review was to determine whether methodological improvements have occurred since the Menzies et al. (1999) review.

METHOD

Literature published since the Menzies et al. review was evaluated with regard to the 5 methodological issues identified in that review: (a) the construct of anxiety, (b) trait anxiety measures, (c) participant numbers, (d) treatment status of participants, and (e) speaking tasks.

RESULTS

Despite some remaining ambiguous findings, research published since the Menzies et al. review has provided far stronger evidence of a relationship between stuttering and anxiety, and has focused more on social anxiety, expectancies of social harm, and fear of negative evaluation.

CONCLUSION

The aims of future research should be to improve research design, increase statistical power, employ multidimensional measures of anxiety, and further develop anxiolytic treatment options for people who stutter.